NCLEX-PN
Maternal NCLEX Practice Questions Questions
Extract:
Question 1 of 5
Which laboratory test should the nurse monitor for a client with preeclampsia?
Correct Answer: A
Rationale: Monitoring platelet count is critical in preeclampsia, as low platelets may indicate severe disease or HELLP syndrome.
Question 2 of 5
The nurse is assessing the laboring client who is morbidly obese. The nurse is unable to determine the fetal position. Which action should be performed by the nurse to obtain the most accurate method of determining fetal position in this client?
Correct Answer: D
Rationale: Real-time transabdominal ultrasound (US) is the most accurate assessment measure to determine the fetal position and is frequently available in the birthing setting. US images may be used to assess fetal lie, presentation, and position in the morbidly obese client. Inspection of the abdomen can be used to determine fetal position, but because the client is obese, this is not the most accurate method. Palpation of the abdomen can be used to determine fetal position, but because the client is obese, this is not the most accurate method. Vaginal examination can be used to determine fetal position, but because the client is obese, this is not the most accurate method.
Question 3 of 5
Which response by the nurse is best?
Correct Answer: B
Rationale: No safe level of alcohol consumption during pregnancy has been established, as it may cause fetal alcohol spectrum disorders.
Question 4 of 5
Which sign of labor should the nurse teach the client to report immediately?
Correct Answer: C
Rationale: Rupture of membranes (water breaking) requires immediate reporting, as it may indicate the onset of labor or risk of infection.
Question 5 of 5
The laboring multigravida client’s last vaginal examination was 8/90/+1. The client now states feeling rectal pressure. Which action should the nurse perform first?
Correct Answer: D
Rationale: The nurse should first evaluate labor progress by performing another vaginal exam. Previously the client was almost fully effaced (90%), and fetal station was 1 cm below the ischial spines (+1). Rectal pressure is often due to pressure exerted during descent of the fetal presenting part. The client needs to be fully dilated (10 cm, not 8 cm) and fully effaced (100%, not 90%) before being encouraged to push. Pushing too early may cause cervical edema and lacerations and may slow the labor process. Rectal pressure may indicate that the client has progressed since the last vaginal exam. Another vaginal exam should be performed before contacting the obstetrician or midwife. During labor, rectal pressure is usually not due to the need for a bowel movement because intestinal motility decreases.